Cycle 1
Health 2024-11-15 · Fire 2024-11-15
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Greenville, SC
West Village Post Acute
3-star overall rating with 3-star inspections with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
8 North Texas Avenue, Greenville, SC
(864) 295-1331
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
132
Certified beds
Average residents
127
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1975-09-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.80
Licensed practical nurse staffing · state 1.01 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.22 · national 2.35
Total nurse hours
3.21
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
2.75
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.49
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
82%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
65%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,073
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.07
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
1.76
Baseline 75.68% · Performance 64.17% · Measure score 1.76 · Achievement 0 · Improvement 1.76
Adjusted total nurse staffing
1.05
Baseline 3.11 hours · Performance 3.38 hours · Measure score 1.05 · Achievement 1.05 · Improvement 0.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.64% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 14.29% · Lower 95% interval 6.78% |
| Discharge to community | 42.15% |
50.57%
8.4 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 32.14% · Lower 95% interval 29.68% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.45% |
95.27%
0.2 pts better
|
Numerator 21 · Denominator 22 |
| Falls with major injury | 4.55% |
0.77%
3.8 pts worse
|
Numerator 1 · Denominator 22 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4.55% |
2.29%
2.3 pts worse
|
Numerator 1 · Denominator 22 · Adjusted rate 3.97% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 22 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 141 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 119 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
90.5%
6 pts better
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 99.2% · Q3 94.9% · Q4 92.4% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.4% |
90.6%
7.8 pts better
|
95.5%
2.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.0%
1 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.3% · Q3 3.4% · Q4 4.2% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.3% |
2.9%
1.4 pts worse
|
11.4%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.0% · Q3 6.7% · Q4 4.0% · 4Q avg 4.3% |
| Percentage of long-stay residents who lose too much weight | 4.8% |
6.2%
1.4 pts better
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 5.5% · Q3 2.8% · Q4 3.7% · 4Q avg 4.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 35.1% |
20.4%
14.7 pts worse
|
19.6%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.7% · Q2 35.7% · Q3 33.6% · Q4 35.5% · 4Q avg 35.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
16.3%
0.5 pts better
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 15.8% · Q3 13.5% · Q4 18.2% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.6% |
14.9%
8.3 pts better
|
16.3%
9.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 2.8% · Q3 2.5% · Q4 11.3% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.7% |
12.4%
7.7 pts better
|
14.9%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.9% · Q3 8.1% · Q4 3.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.6%
1.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
17.2%
4.6 pts worse
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.1% · Q2 17.5% · Q3 19.2% · Q4 31.7% · 4Q avg 21.8% |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
5.8%
1.5 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 9.1% · Q3 4.0% · Q4 5.7% · 4Q avg 7.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 38.6% |
79.8%
41.2 pts worse
|
81.7%
43.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 49.1% · Q2 38.5% · Q3 36.4% · Q4 33.3% · 4Q avg 38.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.3% |
14.1%
0.2 pts worse
|
12.0%
2.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.3% · Observed 17.4% · Expected 13.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.8% |
1.6%
2.2 pts worse
|
1.6%
2.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 2.4% · Q4 7.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 40.0% |
78.0%
38 pts worse
|
79.7%
39.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 40.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.6% |
24.7%
5.9 pts worse
|
23.9%
6.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.6% · Observed 34.8% · Expected 27.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-10-13 · Fire 2022-10-13
12 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-04-30 · Fire 2021-04-30
7 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-15
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2024-12-16
D · Potential for more than minimal harm
2022-10-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-28
D · Potential for more than minimal harm
2022-10-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-28
D · Potential for more than minimal harm
2021-04-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-05-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2026-02-10
D · Potential for more than minimal harm
2025-03-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-07
E · Potential for more than minimal harm
2024-11-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-15
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-11-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-10
D · Potential for more than minimal harm
2023-07-11
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-17
G · Actual harm
2022-10-13
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-11-13
F · Potential for more than minimal harm
2022-10-13
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-13
E · Potential for more than minimal harm
2022-10-13
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-10-13
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-10-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-10-13
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-10-13
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-10-13
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-10-13
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-10-13
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-10-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-11-13
D · Potential for more than minimal harm
2022-10-13
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-11-13
E · Potential for more than minimal harm
2021-04-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-06-30
D · Potential for more than minimal harm
2021-04-30
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-06-30
D · Potential for more than minimal harm
2021-04-30
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2021-06-30
D · Potential for more than minimal harm
2021-04-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-06-30
D · Potential for more than minimal harm
2021-04-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-06-30
D · Potential for more than minimal harm
2021-04-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-02
Penalties and ownership
What sits behind the stars
Ownership
Providence Group Nh, LLC
5% Or Greater Direct Ownership Interest · Organization
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Holck, Justin
Operational/Managerial Control · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mauldin, Elizabeth
Operational/Managerial Control · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Truist Bank
5% Or Greater Security Interest · Organization
Wheeler, Kerry
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Magnolia Manor - Greenville
Greenville, SC
3-star overall rating with 2-star inspections with $4,271 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Greenville Post Acute
Greenville, SC
2-star overall rating with 2-star inspections with $5,831 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Heartland Health Care Center - Greenville East
Greenville, SC
5-star overall rating with 4-star inspections with $38,389 in total fines with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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